Understanding offending behaviour in people with ASD

15.35 - 16.35

Dr Juli Crocombe, Consultant Forensic Psychiatrist in Neurodevelopmental Disorders at St Andrew's and Chair of the Advisory Board to the All Party Parliamentary Group on Autism

Dr Juli Crocombe

Consultant Psychiatrist

Clinical Director for Autism and ID Services

Understanding and Supporting People

with Autism who Offend

Overview • History

• Policy context

• The Bradley Report

• Building the Right Support

• Offender Pathway

• Care and Treatment

• Challenges/opportunities

• Time for Change: the Challenge Ahead

History

• Lack of awareness of ASD

• Failure to recognise / diagnose ASD

• Misdiagnosis

• Lack of support / specialist provision

• Lack of appropriate care and treatment

• Inappropriate care and treatment

Policy Context

• Autism Act 2009

• Autism Strategy 2010

• NICE Guidelines 2012

• Transforming Care 2012

• NICE Quality Standard 2014

• Autism Strategy review 2014

Autism Strategy review 2014

• Preventative support and safeguarding

• Reasonable adjustments and equality

• Supporting people with autism and complex needs

• Employment

• Criminal justice

Criminal Justice System

Cross Government Group to consider and take

forward issues to do with autism and the CJS:

• Police

• Liaison and Diversion

• Courts

• Prisons

• Probation

The Bradley Report

Recommendations • Prevention and early intervention;

• Access to liaison and diversion services;

• Special provisions for vulnerable defendants in court;

• Speedier court reports on mental health;

• Adequate alternatives to prison for vulnerable offenders where

appropriate;

• Better screening for mental health and learning disabilities on arrival

at prison;

• Greater continuity of care as people enter prison and as they leave

prison to re-enter the community;

• Help to be given to petty offenders with mental health problems or

learning disabilities to ensure they are helped to stay out of trouble.

Building the Right Support

Aims

• Transform the care of people with LD and/or

autism who have a mental health condition

or display behaviour that challenges (inc

offending behaviours);

• Enable more people to live safely and

happily in the community

Principles

• I have choice and control over my care

• My care is proactive, planned and coordinated

• I live in the community with support from and for my family and carers

• I have a choice about where I live and who I live with

• I have a fulfilling and purposeful everyday life

• I get good care from mainstream NHS services

• I can access specialist health and social care support in the

community

• I am supported to stay out of trouble

• When I need the additional care and support a hospital provides,

I get high-quality care and don’t stay there longer than I need to.

I am supported to stay out of trouble

• Community ‘forensic’ services to:

- identify risks and address them;

- establish links with other services/agencies to

facilitate pathways away from the CJS;

- provide advice and support to other

services/agencies to ensure early intervention;

- provide offence-specific interventions;

- provide a care co-ordination function.

When I need hospital, I get high-quality care and don’t stay there longer than I need to.

• Secure services should:

– only be for people with ASD who present risks that

cannot be managed safely in the community;

– offer evidence based interventions delivered by

appropriately qualified staff and meeting relevant

accreditation;

– function as an integral part of a wider care pathway;

– have strong relationships with the justice service.

Offender Pathway

Arrest

Autism Alert Card

• Credit card size

• In association with police forces

• Supported by training of police officers

• For use in emergency situations

Autism Alert Cards

Autism Alert Cards

Police Station / Custody

Fitness to be Interviewed

Custody Officer must determine and consider:

• the risks to the detainee’s physical and mental

state if the interview took place;

• what safeguards are needed to allow the interview

to take place.

Appropriate Adult

• Special protection for mentally disordered or mentally vulnerable persons in custody.

• Ensures that they have a responsible person with them in the custody suite when important actions or decisions take place

Liaison and Diversion

• Prevent crime

• Reduce re-offending

• Provide better and more timely information to agencies in the criminal justice system.

Courts / Trial

Advocacy

‘Questioning that contravenes principles for

obtaining accurate information from a witness

by exploiting his or her developmental

limitations is not conducive to a fair trial and

would contravene the Codes of Conduct’.

Advocate’s Gateway

• Free access to practical, evidence-based

guidance on vulnerable witnesses and

defendants;

• Toolkits that provide general good practice

guidance when preparing for trial in cases

involving a witness or a defendant with

communication needs;

Toolkit 3

• Someone with autism falls within the

definition of a vulnerable witness.

• Courts must make reasonable adjustments

to remove barriers for people with

disabilities, including autism.

• There should be a presumption in favour of

a supporter as a special measure.

Fitness to Plead

• Purpose is to strike a fair balance between:

- the need to protect a defendant who has, in

fact, done nothing wrong but is unfit to plead

at their trial;

- the need to protect the public from a

defendant who has committed an act which

would be a crime if they were fit to plead

Criteria for making a Hospital Order

• The defendant must be:

- convicted of an offence punishable with

imprisonment; or

- found unfit to plead and to have committed

the act or made the omission.

Criteria for making a Hospital Order

• The Court must be satisfied on the written

or oral evidence of two doctors that:

- the defendant is suffering from a mental

disorder of a nature or degree which makes

it appropriate for the defendant to be

detained in hospital for medical treatment;

and

- appropriate medical treatment is available.

MHA Code of Practice • Compulsory treatment in a hospital setting is rarely likely to be

helpful for a person with autism.

• If people with autism do need to be detained under the MHA, it is

important that they are treated in a setting appropriate to their social

and communication needs as well as being able to treat their mental

condition.

• Practitioners working with or detaining people with autism should

have relevant specialist training and experience.

• People with autism should be detained for as short a period as

possible.

• Reasonable adjustments required by the Equality Act must be made.

• Providers must have autism specific policies and practices.

Care and Treatment

The nature of Autism

• Autism is a

DEVELOPMENTAL DISORDER

• It is not an illness.

What does this mean?

• YOU CANNOT ‘TREAT’ AUTISM per se;

• YOU CAN TREAT:

- CO EXISTING PHYSICAL ILLNESS;

- CO EXISTING MENTAL ILLNESS;

- TROUBLESOME FEATURES OF AUTISM including anxiety

Implications

• Correct recognition and diagnosis of autism is

vital.

• Correct recognition and diagnosis of co existing

physical and / or mental illness essential.

• Correct recognition and diagnosis of other co

existing conditions essential.

• Detailed assessment to develop full and accurate

understanding of nature and cause of new or

different behaviours is essential.

Co existing Physical Illness

• “..significant physical health problems can also be

present in adults with autism.”

• “..may be unrecognised or not treated, in part

because the person with autism had not

complained of any such problems or had not been

able to communicate their concerns in a way that

had been understood.”

NICE 142 page 132-3 ‘Assessment of coexisting conditions’

Co existing Mental Illness

• Identification and treatment of co existing mental

illness affects the long-term outcome

• People with autism are at increased risk of mental

illness (Joshi et al, 2013)

• 9% of children & adolescents with autism

(Ghaziuddin et al, 1992)

Other Co existing Conditions

• Personality traits / disorders

• ADHD

- increasingly recognised

- differential diagnosis can be difficult and complex

- co existing or feature of ASD?

- which is primary, ASD or PD / ADHD?

- ‘psychopathy’ / callousness especially ‘risky’

Assessment

• Full physical history and examination

• Full psychiatric history and mental state examination

• Specialist autism assessment

• Environmental review

• Communication assessment

• Sensory assessment

• Functional analysis

NICE Quality Statement 7

Assessing possible triggers for behaviour that

challenges.

“People with autism who develop behaviour that

challenges are assessed for possible triggers,

including physical health conditions, mental health

problems and environmental factors.”

Formulation

• Diagnosis

• Aetiology

• Interventions / treatment

Diagnosis

• Autism

? plus

• Co existing condition

Aetiology

Predisposing Precipitating Perpetuating

Biological

Psychological

Social

Aetiology in Autism

Predisposing Precipitating Perpetuating

Biological

Psychological

Social

Environmental

Communication

Sensory

Features of ASC that Predispose to

Offending

Core problems

• Theory of mind deficits

- impaired empathy

• Impaired executive function / central

coherence

• Impaired mental processing

• Sensory integration

2* or 3* problems

• High anxiety / impulsivity

• Poor judgement / common sense

• Low intellectual functioning

• Morbid preoccupations

• Extreme rigidity

• High fantasy content and poor self

regulation

Nature of Offending Behaviour

• Exploitation by others

• Violence

• Anti-social behaviour

Exploitation

• Social naivety

• Social isolation and vulnerability

• Seeking social approval

• Literal interpretation of language

• Bullied, threatened or coerced

Violence

• Disruption to routine or social adjustment

• Frustration at social limitations

• Imposition of routines on self and others

• Reaction to others

• Misinterpretation of intentions of others

• Fascination with weapons, poisons, chemicals etc

• Co morbid psychiatric and other problems

Anti – Social Behaviour

• Poor comprehension of social rules

• Rigidity and repetitiveness

• Impaired empathy

• Social isolation

• Literal understanding of language

• Imposition of rituals or routines on self and others

• Sadistic tendencies

• Morbid, compulsive fantasies or interests

• Co morbid psychiatric disorder

Interventions / treatment

• Biological

• Psychological

• Social

• Environmental

• Communication

• Sensory

Accessing Healthcare

4.2 “Adults with autism should be able to benefit fully

from mainstream public services to live

independently and healthily.”

4.5 “Autism Passports….allow people to carry with

them information about themselves....to share with

services what adjustments they need.”

Think Autism – update to the Autism Strategy, April 2014.

My Hospital Passport

• Intended to assist hospital staff to provide the best

possible healthcare to the individual with autism.

• Available from the NAS.

• Guidance notes to help in completion with the

most useful information to aid assessment and

treatment.

Biological – mental illness

• Informed by NICE guidance for the specific

disorder

• Psychotropic medication

- antidepressants

- mood stabilisers

- anxiolytics

- (antipsychotics)

Psychological – mental illness

• Informed by NICE guidance for the specific

disorder

eg Cognitive Behavioural Therapy (CBT) for

depressive disorder

• Delivered with an understanding of the core

features of autism

• Adapted

Psychological – personality disorder

• Informed by NICE guidance for PD

eg Dialectical Behaviour Therapy (DBT)

• Delivered with an understanding of the core

features of autism

• Adapted

Psychological – ‘challenging behaviour’

• Behavioural therapy (functional analysis)

• Anger management interventions

• Supportive

Social

• Social learning programmes

• Structured leisure activity programme

• Supported employment programme

• Support for families, partners and carers

Environmental

• Carers – family/staff

• Physical environment

• Structure/routine

• Fellow residents/patients

Communication

• Carer awareness

• SALT

• Visual cues

• Specific strategies

Sensory issues

• Full sensory integration assessment

• Ensure all carers know and understand sensory

integration profile

• Strategies and interventions to modulate sensory

integration difficulties

- Weighted blanket

- Low lighting

- Colours

NICE Quality Statement 8

Interventions for behaviour that challenges

“People with autism and behaviour that challenges

are not offered antipsychotic medication unless it is

being considered because psychosocial or other

interventions are insufficient or cannot be delivered

because of the severity of the behaviour.”

Risk Assessment

• Existing tools don’t address:

- ASD specific risks

- internet related risks

• Accordingly, danger of:

- overestimating risk

- underestimating risk

Outcome Measures

• Existing tools:

- based on neurotypical values

- based on concept of ‘recovery’

• Accordingly:

- fail to measure change

- are meaningless to the person with ASD

Challenges / Opportunities

Service Provision

• Closure of inpatient services

• Failure to distinguish between needs of:

- ASD + ID vs ASD – ID;

- ‘Challenging’ vs Offending Behaviour

Discharge

• I can’t access:

- appropriate care and treatment

- specialist health and social care support in

the community

- community ‘forensic’ services

Results

• Lack of appropriate health and social care

support

• More people with ASD come into contact

with the CJS

• More people with ASD go to prison

• Increase risk of harm to self and others

Time for Change: the Challenge Ahead

Key Recommendations

• Prevention Revolution

• PBS Standard and tiered accreditation systems

• Continuing investment for capital projects to support

discharge

• Establishment of a Social Property Fund

• Exemption for supported housing from capping of housing

benefit

• Independent evaluation of the Transforming Care

programme

• Learning Disabilities Commissioner

jcrocombe@standrew.co.uk